A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Monitor oxygen saturation (SpO2) via continuous pulse oximetry.

Observe neck for jugular vein distention.

Notify healthcare provider to prepare for pericardiocentesis.

Assess for paradoxical blood pressure.

Answer and Explanation

The Correct Answer is C

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Correct Answer is B

Explanation

A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.

B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.

C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.

D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

A. An older adult who is scheduled for foot amputation due to diabetes complications. B. An adult with alcoholism, cirrhosis, and hepatic encephalopathy. C. An older client who is one day postoperative with a colostomy for colon cancer. D. An adult who is one day postoperative for a laparoscopic cholecystectomy.

Correct Answer is D

Explanation

A. An older adult scheduled for foot amputation due to diabetes complications may have complex care needs requiring the expertise of an RN.

B. An adult with alcoholism, cirrhosis, and hepatic encephalopathy can present with unstable and complex health issues that require close monitoring by an RN.

C. An older client who is one day postoperative with a colostomy for colon cancer may require specialized care and education best provided by an RN.

D. An adult who is one day postoperative for a laparoscopic cholecystectomy is likely to have more predictable and routine care needs, making this client a suitable assignment for a PN under the supervision of an RN.

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A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is D

Explanation

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